Arkansas Department of Human Services - humanservices arkansas 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This is essential for tracking purposes.
3. Fill in the name and address of the person being examined, ensuring accuracy for proper identification.
4. If applicable, provide the name of the parent or guardian if the individual examined is a minor.
5. Sign in the designated area if you are a parent or guardian, confirming consent for medical information release.
6. Complete the Physician’s Report section by filling out details such as DOB, height, weight, and health assessments across various categories like 'Chest/Lungs' and 'Heart'.
7. List any medications that may affect caregiving abilities and chronic conditions treated in the last six months.
8. For children, indicate if immunizations are up to date; for adults, assess suitability for child care responsibilities.
9. Finally, have your physician print their name, sign, and date at the bottom of the form before submission.

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